Moisture-associated skin damage (MASD) is a common problem for wound clinicians. It connotes a spectrum of skin damage caused by inflammation and erosion (or denudation) of the epidermis resulting from prolonged exposure to various sources of moisture and potential irritants. These can include...
by Holly M. Hovan MSN, APRN-ACNS-BC, CWOCN-AP
Medical adhesive-related skin injury, or MARSI, is a common type of skin injury, often seen in inpatient settings and in vulnerable populations with fragile skin such as older adults (decreased elasticity, usually multiple pre-existing comorbidities) or pediatric patients (skin is not fully developed). MARSI is caused by trauma to the skin from medical adhesives (think of things such as… tape used to secure a dressing after a blood draw, clear film dressings, ostomy pouches, external catheters in men, tube securement devices, surgical dressings, etc.). MARSI is not a pressure injury and is not caused by pressure.
Anytime we are consulted or asked to follow up on a new wound, one of the things we are assessing for is the cause of the wound or injury—trauma, pressure, moisture, friction, shear, impaired blood flow, etc. It is important to look at the big picture and what caused the wound or skin injury. Many variables can and do make wounds and skin conditions worse, but when determining the true etiology, we must look at what initially caused the problem.
The stratum corneum, or the outermost layer of the epidermis, is typically the layer of skin that is affected most by MARSI because it is what serves as a barrier against the environment and environmental factors such as adhesives, moisture, friction, etc.
MARSI typically manifests as a skin tear with a flap attached or detached, blistering, moist or macerated skin (think of when a Band-Aid or dressing is left on too long and the skin becomes white and moist underneath), folliculitis, skin stripping, or superficially denuded skin (e.g., contact irritant dermatitis). MARSI may occur as soon as the adhesive is removed; for example, we may see the tear happen as the tape or ostomy face plate is removed, or it may pop up a brief time later after skin is exposed to the environment. MARSI is typically erythematous in appearance, and patients with intact sensory perception usually have pain.
Underlying Risk Factors
Many factors can place someone at a higher risk for MARSI, and some of which are discussed earlier: older adults, infants, those with already fragile skin (taking blood thinners, steroid therapy, chemotherapy, neuropathy or impaired sensory perception, etc.). Many of the MARSIs discussed can be prevented. When not completely preventable, MARSI is typically easily treated by removing the offending factor when able (e.g., using paper instead of nylon tape) and applying a non-adherent dressing until the issue is resolved.
Prevention and Treatment
Some strategies to prevent MARSI are:
- Identifying patients at elevated risk and implementing interventions before MARSI occurs
- Using paper or soft cloth instead of nylon tape
- Using adhesive remover when able or appropriate to remove heavy tape, tube securement devices, and ostomy pouches
- Keeping skin well moisturized when appropriate (e.g., not underneath an ostomy barrier but on arms and legs)
- Using protective devices such as skin sleeves to keep at-risk areas covered (also protects from skin tears)
- Changing devices that are adhered to the skin (ostomy pouches, tube securement devices) on a routine basis such as biweekly and/or as needed or per your institution’s protocol
- Using a skin sealant to protect at-risk areas when preparing the skin before application of an adhesive device
- Removing tape and/or device in the direction that the hair is growing
To treat MARSI, we want to prevent infection, limit pain, and manage wound drainage while promoting healing. It is important to promote a moist wound environment for healing; however, we want to limit excessive moisture to prevent maceration. MARSI can typically be treated easily and, like skin tears, with a non-adherent, breathable layer followed by a secondary dressing, changing two to three times per week and more frequently as needed. Normal saline is an appropriate cleansing agent if infection is not suspected.
As with pressure injuries and skin tears, prevention is key, especially because research shows us that most types of MARSI are preventable. Identify patients at elevated risk for MARSI early, and be sure that interventions for prevention are in place, reassess and update the plan of care as needed, and utilize your interdisciplinary team as appropriate.
About the Author
Holly is a board certified gerontological nurse and advanced practice wound, ostomy, and continence nurse coordinator at The Department of Veterans Affairs Medical Center in Cleveland, Ohio. She has a passion for education, teaching, and our veterans. Holly has been practicing in WOC nursing for approximately six years. She has much experience with the long-term care population and chronic wounds as well as pressure injuries, diabetic ulcers, venous and arterial wounds, surgical wounds, radiation dermatitis, and wounds requiring advanced wound therapy for healing. Holly enjoys teaching new nurses about wound care and, most importantly, pressure injury prevention. She enjoys working with each patient to come up with an individualized plan of care based on their needs and overall medical situation. She values the importance of taking an interprofessional approach with wound care and prevention overall, and involves each member of the health care team as much as possible. She also values the significance of the support of leadership within her facility and the overall impact of great teamwork for positive outcomes.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.